Guidance on standards for training in smoking cessation practice in Wales
Contents Page 1.0 Introduction 3 1.1 Purpose of this document 1.2 Levels of training for smoking cessation interventions 1.3 Who is this document for? 2.0 The problem of smoking in Wales 5 2.1 Smoking: the facts 2.2 The importance of smoking cessation 2.3 Stop Smoking Wales 3.0 Four levels of intervention 7 3.1 Awareness raising 3.2 Brief intervention 3.3 Intensive one-to-one behavioural support 3.4 Intensive group-based behavioural support 4.0 Standards for training in smoking cessation practice 11 4.1 Awareness raising 4.2 Brief intervention 4.3 Intensive one-to-one behavioural support 4.4 Intensive group-based behavioural support 5.0 Guidelines for training 18 6.0 References 19 7.0 Acknowledgements 20 2 October 2010
1.0 Introduction Smoking cessation is a major priority for those involved in the prevention and treatment of tobacco related diseases, and should be a priority for anyone coming into contact with smokers and their families in a health care or community setting. With so many possible champions of smoking cessation it is essential that all follow the same pattern when providing smoking-related interventions, be it basic awareness raising, brief intervention, intensive one-to-one behavioural support or intensive group-based behavioural support. 3 3
1.1 Purpose of this document The purpose of the guidance on standards for training in smoking cessation practice is to: bring consistency of approach to smoking-related interventions across Wales, based on a common understanding of the theory and practice of smoking cessation and tobacco control improve the effectiveness of all those providing smoking-related interventions in Wales shape the content of smoking-related training across Wales so that it equips providers with the knowledge and skills they need to perform their role to the highest standards of practice provide practitioners, Health Boards, Public Health Wales and the Welsh Assembly Government with a strong framework against which to benchmark current and future practice. 1.2 Levels of training for smoking cessation interventions This document sets out a framework of four levels of training in smoking cessation related interventions. It seeks to clarify which level of training is appropriate to the level of smoking cessation intervention being delivered. 1.3 Who is this document for? Commissioners of smoking cessation services so that they have an understanding of the different levels of intervention and the knowledge and skill base that providers should possess at each level. Organisations delivering smokingrelated interventions so that they can assess which level(s) of intervention is appropriate for them to deliver and the associated training needs of their staff. Providers of smoking-related training so that they can shape the content of their training programmes accordingly. Recipients of training so that they are aware of the knowledge and skills that they can gain from the training and the level of intervention they will be equipped to deliver. 4
2.0 The problem of smoking in Wales 2.1 Smoking: the facts Tobacco smoking is the largest single cause of avoidable ill health and early death in Wales. Key issues: 24 per cent of adults in Wales smoke (1) In Wales, around 5,600 deaths each year are caused by smoking (2) Rates of smoking are highest among the most deprived socio-economic groups in Wales (1) In 2007-08, smoking cost the NHS in Wales an estimated 386 million; equivalent to 129 per head and 7% of total healthcare expenditure in Wales (3) 2.2 The importance of smoking cessation Helping people to stop smoking is an essential element of any public health strategy to tackle the chronic disease burden created by tobacco and the social and economic consequences that result. When compared with the cost of treating smoking-related conditions, brief intervention and intensive behavioural support are extremely costeffective measures (4). Key issues: In Wales as a whole, seven in ten smokers surveyed in 2009 expressed a desire to quit; only four in ten tried (1) About two to three per cent of smokers will quit successfully by relying on willpower alone (4) Brief intervention to stop smoking by a medical practitioner can result in a further one to three per cent of smokers quitting successfully (4), and a combination of intensive behavioural support and pharmacotherapy for smoking cessation can increase a smokers chance of quitting to approximately 20 per cent (4,5) Key documents in the development of a public health approach to smoking cessation are the National Institute for Health and Clinical Excellence (NICE) guidance on Brief interventions and referral for smoking cessation in primary care and other settings (6) and Smoking cessation services (7). These documents set out the public health need, identify key target groups and provide guidance for smoking cessation services. 5
2.3 Stop Smoking Wales Following the publication of the 1998 UK White Paper Smoking Kills (8), a number of pilot community-based smoking cessation projects were set up in Wales in 2000. This was followed by the establishment of the All Wales Smoking Cessation Service, which, in 2007, was re-launched as Stop Smoking Wales. Stop Smoking Wales is funded by the Welsh Assembly Government and is an integral part of Public Health Wales. It is a free NHS service to help smokers who are motivated to stop smoking. Stop Smoking Wales has three key aims: to train healthcare and community workers to deliver brief intervention for smoking cessation to encourage referrals to the service to provide a community based intensive behavioural support programme offering choice and access to smokers who want to give up smoking to provide public health advice and support to local and national tobacco control initiatives. 6
3.0 Four levels of intervention The following section sets out the four levels of intervention covered by the standards for training in smoking cessation practice in Wales. 3.1 Awareness raising Awareness raising is important as a first step in the smoking cessation process. The purpose of awareness raising is to help smokers consider more fully the importance of stopping smoking and some of the health benefits they may gain as a result. Awareness raising takes no longer than a couple of minutes, is opportunistic in nature, should direct smokers to sources of information and advice where smoking cessation can be discussed and explored in more detail. 3.1 Awareness raising Why provide awareness raising? It is important in motivating behaviour change and raising the profile of smoking cessation services. Who should attend training in awareness raising? Anyone who is expected to raise the issue of smoking with clients including: all health and social care professionals youth and community workers teachers substance misuse workers prison officers. What is the minimum training time required? Half a day. 7
3.2 Brief intervention 3.2 Brief intervention The National Institute for Health and Clinical Excellence describes brief interventions (6) as involving opportunistic advice, discussion, negotiation or encouragement. For smoking cessation, brief intervention (6) typically takes between five and ten minutes and may include one or more of the following: simple opportunistic advice to stop an assessment of the client s commitment to quit an offer of pharmacotherapy and/or behavioural support provision of self-help material and referral to more intensive support such as Stop Smoking Wales. Why provide brief intervention? It is a cost effective public health measure that can be delivered by a broad base of practitioners. An unassisted quit rate of two to three per cent (4) can be increased by a further one to three per cent (4) with brief intervention from a medical practitioner. It can raise the profile of and increase access to smoking cessation services. Who should attend training in brief intervention? Anyone who is expected to promote smoking cessation with clients including: all health and social care professionals youth and community workers teachers substance misuse workers prison officers. What is the minimum training time required? One full day. 8
3.3 Intensive one-to-one behavioural support Intensive one-to-one behavioural support typically involves an initial assessment of the client s needs followed by a six-week behavioural support programme, covering the period immediately prior to the quit attempt and the initial weeks following it. Why provide intensive one-to-one behavioural support? Who should attend training in intensive one-to-one behavioural support? It adds about seven per cent to the unassisted quit rate without medication (5) and up to 17 per cent when combined with pharmacological therapies to smoking cessation (4,5). It provides on-going support to the client, which is important in terms of positive reinforcement and reassurance. Anyone planning or delivering intensive one-toone support sessions. 3.3 Intensive one-to-one behavioural support What is the minimum training time required? Three days. 9
3.4 Intensive group-based behavioural support 3.4 Intensive group-based behavioural support Intensive group-based behavioural support typically involves an individual initial assessment of the client s needs followed by a six-week (closed a ) group-based behavioural support programme, covering the period immediately prior to the quit attempt and the initial weeks following it. The group provides a supportive environment in which people can share experiences, learn from and support each other through the cessation process. Why provide intensive group support? Group processes can sustain and enhance motivation to quit smoking. Groups can be very supportive environments for those attempting to quit smoking. Groups can be more cost effective than one-toone support because of the greater client to smoking cessation advisor ratio. Who should attend training in group-based behavioural support? Anyone planning or delivering intensive group support sessions. What is the minimum training time required? Completion of training in one-to-one intensive support, plus one additional day. a A closed group is a structured, multi-session group programme with pre-arranged start and 10 finish dates and a pre-booked client group.
4.0 Standards for training in smoking cessation practice in Wales 4.1 Awareness raising The following section describes the knowledge and skills that anyone providing awareness raising should possess on completion of the appropriate training and the actions that they should be able to take. 4.1 Awareness raising The rationale for awareness raising To be able to explain in simple and concise terms the importance of trying to stop smoking. To understand the role of awareness raising in behaviour change theory. To be able to recognise the opportunities in which it is appropriate to raise awareness and those when it is not. Smoking and health To understand and be able to describe the impact of tobacco on human physiology, including the main diseases and specific risks associated with certain conditions such as childhood asthma, diabetes or pregnancy. To be able to describe the short and long term health benefits of stopping smoking. To be able to explain the risks associated with second-hand smoke. To be able to personalise health information in an empathetic manner according to the client s own circumstances and lifestyle. Prompting a quit attempt To be able to ask if the client wants to stop smoking. To be able to promote local evidencebased cessation services. 11
4.2 Brief intervention 4.2 Brief intervention The following section describes the knowledge and skills that anyone providing a brief intervention should possess on completion of the appropriate training, and the actions that they should be able to take. The rationale for brief intervention To be able to personalise health information in an empathetic manner To understand the meaning and purpose according to the client s own of brief intervention. circumstances and lifestyle. To understand local and national To be able to describe the short and long smoking cessation policies. term benefits of stopping smoking. To understand local and national To be able to explain the issue and risks prevalence rates. associated with second-hand smoke. To be aware of and comprehend the cost To be aware of the nature of the effectiveness of brief intervention and relationship between tobacco and health other cessation interventions. inequalities. To be familiar with and understand the evidence for effectiveness regarding brief Communicating effectively intervention and the need to integrate it into normal working practice. To be empathetic and non-judgemental. To understand the benefits and limitations of brief intervention. To be familiar with and understand the recommendations concerning frequency of intervention, when not to offer it, and to be aware of the other situations where brief intervention may have recently been provided. Smoking and health To have a basic understanding and be able to simply describe the impact of tobacco on human physiology including the main diseases and specific risks associated with certain conditions such as childhood asthma, diabetes, or pregnancy. To possess basic interview techniques to: - listen effectively (active listening) - know how and when to use different styles of questioning (closed versus open and the importance of both) - be able to respond appropriately, for example, by offering encouragement, and challenging or dispelling myths. Assessing a client s tobacco use To be able to raise the issue of smoking and smoking cessation in an appropriate way. To be able to ascertain a client s readiness to quit and then tailor advice accordingly. 12
Prompting and supporting a quit attempt To understand the reasons behind a person s desire to make a quit attempt and then build on these to develop the person s motivation still further. To understand the barriers and obstacles to quitting and be able to offer advice on how they may be prepared for and overcome: - withdrawal - socialising - habitual use of cigarettes, for example, when answering the phone or drinking coffee. To understand the mechanism of nicotine addiction. To be aware of the reasons given (i.e. the perceived benefits) for continuing to smoke, and to be able to work with clients to address any misconceptions they may have. To understand the social and behavioural aspects of smoking. To be able to explain the benefits of complete cessation over the risk of cutting down. To be able to describe the evidencebased interventions that are available to help a client quit smoking (including behavioural support and pharmacological therapies) and how, when and with whom they can and should be used. Local cessation services To be able to describe the support that is available locally. To be able to promote the service. To know how to refer clients to the service. To know how and who to access for information about local services and to be able to direct people to evidence-based, reliable sources of information. Resources To be able to refer clients to a wide range of resources including websites, paper copy and telephone helplines. To be able to use resources with clients, for example the carbon monoxide monitor, cards or booklets. To know where to get help when dealing with complex client presentations. To be able to maintain knowledge and understanding through training and the review of appropriate papers and research studies. Monitoring and data collection To be able to follow local and national guidelines on monitoring and evaluation. To be able to record key data on the intervention with the client, where appropriate. 4.2 Brief intervention 13
4.3 Intensive one-to-one behavioural support 4.3 Intensive one-to-one behavioural support The following section describes the understanding and skills that anyone providing intensive one-to-one behavioural support should possess on completion of the appropriate training and the actions that stem from it. Note: Participants should have completed training in brief intervention before covering the following topics, or the topics on brief intervention should be included in the training for intensive one-to-one support. The background to specialist cessation support To understand and be able to explain the rationale, benefits and use of specialist support. To understand the variations in smoking prevalence rates due to age, gender, socio-economic status and ethnicity. To understand and respond appropriately to the needs of clients including those in priority groups (including socioeconomically disadvantaged groups). To know where to obtain advice and support when working with clients. Assessing a client s tobacco use To understand why integrated multidisciplinary approaches to smoking cessation are effective and beneficial. To recognise the importance of a partnership approach to smoking cessation and how to facilitate it, including working with other health and non-health professionals. To be aware of other smoking cessation services and how they can be accessed. Understanding and working with clients To understand the complexity of tobacco use in terms of: - physical and behavioural causes - nicotine dependence - tobacco as a stressor - the basic chemistry of tobacco. To be able to assess a client s level of nicotine dependency, past smoking behaviour, including past history of quit attempts. To be able to assess the impact of tobacco use on a client s behaviour. To be able to raise the issue of smoking and smoking cessation in an appropriate way. To be able to ascertain a client s readiness to quit and then tailor advice accordingly. To be able to ascertain a client s readiness and suitability for one-to-one support. To understand and be able to use a carbon monoxide monitor according to best practice standards. To understand the reasons behind using a carbon monoxide monitor to both motivate the client and monitor and evaluate outcomes. 14
The physiology of tobacco To understand and describe the ways in which tobacco is a cause of disease. To understand and describe the impact of tobacco on body systems. To understand and describe the improvement in risk level following cessation. To understand and describe the relationship between tobacco as a risk factor and other lifestyle risk factors (for example, the multiplier effect). Supporting a quit attempt To understand and describe the evidence base on the effectiveness of pharmacological therapies available, intensive behavioural support and to be able to explain this evidence base to clients. To be able to help the client to develop realistic expectations regarding the treatment programme. To be able to list known withdrawal symptoms (common and less common), and their natural time course. To be able to give a detailed explanation of how to prepare a client for a quit attempt. To be able to enable clients to understand the characteristics of their tobacco use (behavioural and physical) and then develop appropriate behavioural support strategies. To apply appropriate behavioural support strategies to enhance a client s motivation. Pharmacological therapies To be able to give a detailed description of: - each of the pharmacological therapies and treatments available - how to use them so as to maximise the likelihood of success - any contraindications, cautions and side effects. To be able to assist a client to choose the most appropriate pharmacological therapy for their needs. To be able to describe the use of the product. To be able to monitor the use of the product by the client. To understand the process and responsibility of prescribing and issuing pharmacological therapy locally. Relapse To understand the distinction between lapse and relapse and how to deal with them. To understand the different triggers for relapse; help the patient to identify and be aware of theirs; assist client in the development of personal coping strategies so that the likelihood of relapse is reduced. To appreciate and be aware of the need for ongoing support, relapse prevention actions after the initial support phase has been completed and identify with the client ways this can be accessed e.g. telephone support. To understand and be able to describe how and when to end treatment. 4.3 Intensive one-to-one behavioural support 15
4.3 Intensive one-to-one behavioural support Monitoring and evaluation To be able to record key data accurately on the intervention with the client and its outcomes (follow up). To be able to maintain accurate records of progress according to the local and national guidelines on monitoring and evaluation. Personal development To appreciate the importance of continuing professional development in smoking cessation work and how and when to access it. To know how and when to obtain support from other cessation advisors and health professionals. To regularly reflect on own practice and assess possible areas for improvement. 16
4.4 Intensive group-based behavioural support The following section describes the understanding and skills that anyone involved in planning or running intensive (closed) group-based behavioural support should possess on completion of the appropriate training and the actions that stem from it. Note: Participants should have completed training in brief intervention and intensive one-to-one behavioural support before undertaking training in intensive (closed a ) group-based behavioural support. Practicalities of setting up and running a (closed) group Understand and be able to plan, organise and deliver a smoking cessation (closed) group. Recruitment and assessment Understand the relative strengths and weaknesses of both (closed) group and one-to-one behavioural support sessions and be able to direct clients to the most appropriate support. Describe content of group support and ways in which group processes can sustain or enhance motivation to quit smoking. Programme for (closed) group support Be able to describe the various treatment programmes on offer, namely intensive behavioural support and pharmacological therapy. Identify which treatment options might be preferable and beneficial for each participant in the group. Encourage members of the group to foster a sense of responsibility to the group. Understand group dynamics and be able to manage and run the group so that all participants feel equally engaged and involved in group discussion. Encourage group members to share experiences of quitting. Monitoring evaluation To be able to record key data accurately on the intervention with the client and its outcomes (follow-up). To be able to maintain accurate records of progress according to the local and national guidelines on monitoring and evaluation. Personal development To appreciate the importance of continuing professional development in smoking cessation work and how and when to access it. To know how and when to obtain support from other cessation advisors and health professionals. To regularly reflect on own practice and assess possible areas for improvement. 4.4 Intensive group-based behavioural support 17
5.0 Guidelines for training The following points do not provide an exhaustive list of the requirements for training; rather they are suggestions for some of the basic criteria that should be met by the trainer and the course they deliver. The skill, knowledge and experience of the trainer Trainers should themselves be trained and experienced in training delivery and, ideally, in smoking cessation work. The trainers own knowledge and skills in relation to tobacco, smoking and cessation should be relevant and current and must cover the following topics: - the broad tobacco control agenda - tobacco and health in terms of: the health consequences of tobacco use the benefits of cessation at an individual and population health level evidence based practice pharmacological therapies the needs of different groups and how to meet them. Training methods The course should be interactive in nature and have an appropriate balance between theoretical and practical learning. A variety of training methods should be utilised to maintain participant s interest and cater to different learning styles. Size of training group In order to facilitate discussion and be engaging it is suggested that groups are no smaller than eight persons and no larger than 16 persons. Follow up Learning should influence practice and it is important that managers discuss with participants the impact of the training on their practice. A follow up course, three to six months later, where participants can return to discuss how their practice has changed as a result of their learning, is beneficial. All courses and learning should be evaluated and feedback should be sought not only from participants at the end of the course but also from their managers and sponsoring organisations. In this way the true impact of the training can begin to be assessed. 18
6.0 References (1) Welsh Assembly Government. Welsh Health Survey 2009. Cardiff: WAG; 2010. (2) Public Health Wales. Lifestyle and health: Wales and its Health Boards. Cardiff: Public Health Wales; 2010. (3) Phillips CJ, Bloodworth A. Cost of smoking to the NHS in Wales. ASH Wales & British Heart Foundation Cymru. Swansea: Swansea University; 2009. (4) Stead LF et al. Physician advice for smoking cessation. Cochrane Database of Systematic Reviews Issue 2; 2008. (5) West R et al. Smoking cessation guidelines for health professionals: an update. Thorax 2000; 55; 987-999. (6) National Institute for Health and Clinical Excellence. Brief interventions and referral for smoking cessation in primary care and other settings. London: National Institute for Health and Clinical Excellence; 2006. (7) National Institute for Health and Clinical Excellence. Smoking cessation services in primary care, pharmacies, local authorities and workplaces, particularly for manual working groups, pregnant women and hard to reach communities. Public health guidance 10. London: National Institute for Health and Clinical Excellence; 2008. (8) Department of Health. Smoking kills: a white paper on tobacco. London: Department of Health; 1998. 19
Acknowledgements These training standards were produced as a result of a partnership between ASH Wales and Public Health Wales with first draft text developed by Work2health. A consultation event, facilitated by Work2health, took place on the 7 April 2009 which led to refinement and agreement on four levels of intervention for smoking cessation. Those in attendance at the consultation event were: Name Tanya Buchanan Helen Poole Ben Carrick Susanne Renkes Mererid Bowley Margaret Munkley Adrian Beeching Linda Durgan Rhiannon Hobbs Vikki Wood Dr Keir Lewis Owen Evans Marloes Holtkamp Debra Roberts Susan Baboolal Lisa Bartkowiak John Griffiths Organisation ASH Wales Cardiff and Vale University Health Board McNeil Limited Public Health Wales Pfizer Ltd Stop Smoking Wales Swansea University Welsh Assembly Government Wales Centre for Pharmacy Professional Education Welsh Medicines Resource Centre Work2health In developing these standards reference has been made to: Standards for Smoking Cessation Training in Scotland 20 Standard for training in smoking cessation treatments (Health Development Agency).